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Treating Post Traumatic Stress Disorder:Part 2 (revised)

April 12, 2008 on 7:34 pm | In Articles |

Step-By-Step: Breaking down the most effective means of rapidly treating PTSD with Cognitive Behavioral Therapy and Aggressive Treatment of Symptoms.

As identified in “Part 1,” a “traumatic memory” differs from a “painful memory” because the original physiology associated with the traumatic event, essentially remains in place. When a person is exposed to a “trigger” that is directly or indirectly associated with the traumatic event, a re-living of the trauma occurs.

There are traumas and there are traumas. A single traumatic event that is not repeated over and over again, as would be the case in chronic childhood abuse, is less complicated to treat. A traumatic experience that is dealt with sooner than later, also easier to address.

In the case of childhood physical or sexual abuse, treatment, if it occurs at all, will likely happen in adult life. Consequently, multiple diagnoses in addition to PTSD can be expected. Most common co-morbid (multiple) conditions will be Major Depression, Panic, Social Phobia, and Generalized Anxiety Disorder. Personality Disorders or features are also not uncommon.

For the sake of the patient, and in order to optimize the effectiveness of psychotherapy, immediate symptomatic stability on as many fronts as possible is both desireable and necessary. So, the first course of treatment, in my opinion, should be an attempt to aggressively reduce symptoms of Depression and Panic with medication. Simultaneously, it is crucial to tell a patient that this is only a first step and it is designed to bring relief. I believe that every patient must be educated about what their diagnoses are, what their diagnoses mean, why they exist and what we intend to do for them. It is critical to get a good social and medical history so that the therapist can connect the perverbial dots that have brought their patients to this point (crisis) in time. I explain to my patients that it is my intention to take the mystery out of their illness by outlining the cause and effect dynamics that have brought such confusion, pain, conflict and chaos to their lives

Technique as well as  timing are a critical part of treatment. When I am finishing a first appointment with a patient (intake) I will ask them (exact words) what they want from me? Their response to that question is the foundation of (our) treatment goals. Though I will identify, and address clinical symptoms and diagnoses, I want to know exactly what the patient is looking to have happen. Subsequently I will read the prior note to my patient at the onset of their next appointment. I use this approach to stay engaged and focused, to inform and be informed as to what “we” are attempting to accomplish together.

As the first approach in my treatment scenario is aggressive treatment of symptoms with medication, in an almost simulataneous manner I am also asking the patient to tell their trauma story. Initially it will be difficult for the patient to discuss uncomfortable details, which is to be expected and (respected). As medication begins to kick in and the patient becomes less depressed and less anxious, more detailed discussion of the trauma or traumas is approached. With regard to the aforementioned dynamics of “technique and timing, ” it is at this time that an explanation of “Inderal” as a treatment agent for reducing the intensity and/or eliminating “flash backs…nightmares…intrusive memories…and re-living experiences” is introduced.

The cognitive behavioral treatment dynamics of treating PTSD operate on a few dimensions. Once the patients co-morbid symptoms (anxiety, depression, panic) are manageable, Inderal, if working successfully, constrains the “re-living” dynamic that prevents the patient from moving forward. The Therapist then presents the patient with a model, template, paradigm, or script, for understanding and responding too their past traumas. It is useful to think of Cognitive-behavioral therapy as “teaching and coaching.” So, with regards to PTSD subsequent to childhood physical or sexual abuse, the therapist essentially says: PTSD is the equivalent of the brain over-reacting to an event that it cannot possibly understand. Flashbacks are like holographs that repeat and repeat as the brain attempts to comprehend. Because the brain is “over reacting” (PTSD symptoms) to the trauma and because our normal defense mechanisms have been blown away, we are receiving misinformation from our perverbial “broken brains.” When we are dealing with the content of the trauma, which for this article has been defined as childhood physical or sexual abuse, a Cognitive-behavioral approach will explain to the adult that their emotional interpretations of themselves and the trauma will be from the perspective of that abused child. The therapist then attempts to teach the adult who, in many aspects of life has not advanced beyond childhood perceptions, a healing model that will nurture and support that traumatized person; just as an informed and loving parent would, were they able to intervene at the time a trauma occurs to their own child.

The adult remains a child with regards to trust, boundaries, intimacy, and self worth. Though they wear the chronological disguise of an adult, successful emotional mastery would be analogous to putting a six year old behind the wheel of a car; expecting that they should be able to drive. Outwardly to themselves and to others, an adult is driving that car, but inwardly, nothing could be further from the truth. The “coaching” part of Cognitive-behavioral therapy is to recognize exactly where the child left off and the adult needs to begin. So, if the child in question was traumatized at the age of “5″, (developmentally) his/her capacity for reasoning will be quite limited and generally dependent on the influence of an adult (parent) figure.  It is not surprising, then, that you might have an adult who is overly influenced by others at the expense of their own adult instinct or intuition. How they handle adult life conflict will fall in line with aspects of their personality i.e. the extrovert might be excessively impulsive and the introvert, painfully avoidant.  In a cognitive-behavioral model, the therapist conveys the message that: If your development had not been interrupted at the age of 5, here are the emotional and rational challenges and lessons that you would have learned, but did not. (This is the teaching aspect of CBT). The therapist will then take an incremental approach (”abuse by a trusted relative” results in your inability to share personal feelings in an intimate relationship)…and will then present a “non-abuse” prescription for how to determine who is and who is not “trustworthy.” The therapist, by example, also demonstrates (non-intimate) role modeling for healthy trust. For the adult who has sustained ongoing trauma as a child,  the therapist will need to be scrupulous about balancing patience and nurturing, with the new learning that will be necessary for emotional growth. The former is a means toward achieving the latter goal; and is not an end unto itself. Hence, the “kind, compassionate, caring” therapist, lacking any determined pre-abuse and post-abuse model of development, provides only comfort. Though appreciated by the patient, it does little to advance the ultimate goal of how their patient might learn to develop safe and loving , intimate relationships and friendships.

Summarily: The old model for treating PTSD: put out as many fires as possible, help the patient work through their trauma while contending with the reality that to do so, they will have to suffer through painful “re-living” experiences. The new model: put out the most severe fires first, begin a first telling of the trauma by the patient without insisting that they reveal details that will likely trigger “re-living” experiences. Begin treating the patient with Inderal as they begin to address “triggering” details of the trauma. Measure the success of Inderal in reducing or eliminating “re-living” experiences including “flash backs, intrusive thoughts or memories, and nightmares.” Identify how the patient has incorporated the trauma; nurture, teach, guide, lead and coach the patient into an adult separation from their traumatic childhood experience.

Gary F. Burnham LCSW